Nokea
The nurse is reinforcing teaching with a client who had a total knee replacement and has a new prescription for enoxaparin. Which of the following information should the nurse reinforce?
- A. Mild bruising or redness may occur at the injection site.
- B. Eliminate green, leafy, vitamin K-rich vegetables from your diet.
- C. Black stools are a common, harmless adverse effect of the medication.
- D. Take over-the-counter medications such as ibuprofen to relieve mild discomfort.
Correct Answer: A
Rationale: Mild bruising or redness is an expected side effect of enoxaparin. Black stools indicate possible bleeding, and ibuprofen increases bleeding risk. Vitamin K restriction is not necessary.
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The nurse is discussing prostatectomies with a group of men. One man asks which kind of prostatectomy is done for someone who has benign prostatic hyperplasia (BPH). What answer should the nurse give?
- A. Transurethral resection prostatectomy
- B. Suprapubic prostatectomy
- C. Retropubic prostatectomy
- D. Perineal prostatectomy
Correct Answer: A
Rationale: Transurethral resection prostatectomy (TURP) is the most common procedure for BPH, removing prostate tissue via the urethra, minimally invasive compared to open approaches.
Which of the following medications is not considered a neuromuscular blocker?
- A. Anectine
- B. Pavulon
- C. Pitressin
- D. Mivacron
Correct Answer: C
Rationale: Pitressin is a hormone replacement medication.
The nurse is caring for a 5-year-old client with sickle cell disease who is experiencing an episode of acute pain. The client has shortness of breath, nausea with vomiting, and severe generalized body and joint pain. Which of the following findings requires immediate intervention?
- A. enlarged spleen on palpation
- B. hemoglobin level of 9.0 g/dL (90 g/L)
- C. bilateral swelling of the hands and feet
- D. pain rated as 8 on the Wong-Baker FACES Scale
Correct Answer: A
Rationale: An enlarged spleen may indicate splenic sequestration, a life-threatening complication requiring immediate intervention.
The nurse is monitoring a client with suspected pulmonary tuberculosis. Which characteristic signs and symptoms does the nurse expect? Select all that apply.
- A. Dysuria
- B. Jaundice
- C. Low back pain
- D. Night sweats
- E. Weight loss
- F. Purulent or blood-tinged sputum
Correct Answer: D,E,F
Rationale: Night sweats, weight loss, and purulent/blood-tinged sputum are hallmark symptoms of pulmonary tuberculosis.
An adult who is scheduled for surgery tomorrow asks the nurse to arrange for his Healing Touch practitioner to give him healing touch treatments after surgery. The client's daughter who hears the request asks the nurse to explain how Healing Touch can help her father. What information should the nurse include in the response?
- A. Healing Touch makes use of the power of suggestion and can help the person feel more comfortable.
- B. No one really knows how it works, but if a person really wants it, it certainly will not hurt.
- C. The Healing Touch practitioner works within the energy field around the person to facilitate healing and pain relief.
- D. Healing Touch is similar to acupuncture except that pressure is used instead of needles.
Correct Answer: C
Rationale: Healing Touch involves manipulating the energy field to promote healing and pain relief, a recognized complementary therapy.